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CLASSROOM READING
Year : 2019  |  Volume : 5  |  Issue : 3  |  Page : 67-68

Metabolic implications of peritoneal dialysis


Department of Nephrology, Apollo Hospital, Chennai, Tamil Nadu, India

Date of Submission26-Dec-2019
Date of Acceptance10-Jan-2020
Date of Web Publication17-Feb-2020

Correspondence Address:
Dr. K C Prakash
Apollo Hospital, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jrnm.jrnm_61_19

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  Abstract 


Peritoneal dialysis (PD) is a well-accepted form of renal replacement treatment. Glucose is the main agent used as an osmotic agent used in the majority of patients on PD. The other agents used are amino acid and polyglucose solutions in specific circumstances.[ Glucose loading is associated with certain downsides. Increase in plasma glucose leads to increased insulin secretion which leads to increased circulating insulin levels and hyperlipidemia and aggravate atherosclerosis. PD is associated with albumin and amino acid loss on a daily basis, which can be more in highly permeable peritoneal membrane or the presence of peritoneal inflammation.

Keywords: Ages, glucose absorption, hypertriglyceridemia, peritoneal dialysis, ultrafiltration failure


How to cite this article:
Prakash K C. Metabolic implications of peritoneal dialysis. J Renal Nutr Metab 2019;5:67-8

How to cite this URL:
Prakash K C. Metabolic implications of peritoneal dialysis. J Renal Nutr Metab [serial online] 2019 [cited 2020 May 28];5:67-8. Available from: http://www.jrnm.in/text.asp?2019/5/3/67/278614



Peritoneal dialysis (PD) has been well-accepted form of renal replacement treatment. Apart from renal failure, both in acute kidney injury and chronic kidney disease with its comorbid factors having metabolic problems, PD is associated with its own metabolic implications.[1]


  Glucose Absorption Top


Glucose is the main agent used as an osmotic agent used in the majority of patients on PD. The other agents used are amino acid and polyglucose solutions in specific circumstances.[2] Glucose is easily absorbed through the peritoneal membrane depending on the peritoneal membrane permeability pattern. Peritoneal permeability test characterizes the peritoneal membrane which may vary from patient to patient. It has been demonstrated that approximately 60%–80% of glucose is absorbed during each exchange. Shorter the exchange lesser the glucose absorption is seen in automated or intermittent PD. Based on the concentration of glucose used on an average 100–150 g of glucose is absorbed per day which gives an additional 400–600 kcal/day of energy to the patient. This can result in weight gain in the early period of PD which can be a blessing for some patients who are calorie deficient while not so for obese individuals.

Glucose loading is associated with certain downsides.[2] Increase in plasma glucose leads to increased insulin secretion which leads to increased circulating insulin levels and hyperlipidemia. These factors are known to aggravate atherosclerosis that too with insulin resistance seen in chronic kidney disease. Some nondiabetic individuals may require glucose lowering agents such as oral hypoglycemic drugs or insulin.[3] Heat sterilization of PD fluid with glucose in acidic pH can lead to the generation of glucose degradation products (GDP). This can inhibit phagocytosis and bactericidal activity, thereby affecting the defense mechanism of the peritoneum. High concentration of glucose and GDP can lead to advanced glycation end products which can damage the peritoneal membrane and lead to ultrafiltration failure.

To avoid excess glucose absorption, one may have to use less glucose-containing PD solutions which can be possible if the patient is compliant with salt and liquid restriction.[4] The other options are to replace one exchange with polyglucose solution.


  Protein Loss Top


PD is associated with albumin and amino acid loss on a daily basis which can be more in highly permeable peritoneal membrane or the presence of peritoneal inflammation. Protein loss on an average would be 10–20 g/day which is mainly contributed by albumin and to some extent by IgG. This is the reason why most of the PD patients have lower serum albumin levels compared to those on hemodialysis. The amino acid loss also occurs during PD which can be up to 3 gm/day. Protein and amino acid loss can get aggravated during the episode of peritonitis.


  Hyponatremia/hypernatremia Top


PD solution contains 132 meq/L. Sodium imbalance is rarely seen in PD patients except under rare circumstances. Hypernatremia is seen in patients in whom hypertonic solutions are used to achieve rapid ultrafiltration where water is removed faster than sodium.[5] Hyponatremia, in most cases, may not be directly implicated due to PD. This is seen with more water intake, in severe hyperglycemia due to shifting of water into extracellular fluid and diluting serum sodium. Similar dilutional hyponatremia is seen in patients who are using icodextrin. This is due to shift of intracellular water into the intravascular compartment due to the presence of maltose and maltotriose which are osmotically active substances. The decline in serum sodium is modest not having any clinical consequence.


  Lipid Abnormalities Top


Hypertriglyceridemia is commonly seen in PD patients which can be associated with other lipid abnormalities. Hypertriglyceridemia can also independently occur due to glucose loading present in PD fluid. This gets aggravated in diabetic PD patients. Controlling sodium and liquid intake so as minimize high concentration PD solution or using alternative nonglucose-based solution can lower the triglyceride level.[1],[5]


  Other Electrolyte Abnormalities Top


Potassium and magnesium abnormalities are seen in some patients however not implicated due to PD but some other factors due to the patient's condition causing the abnormalities.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pennell P, Rojas C, Asif A, Rossini E. Managing metabolic complications of peritoneal dialysis. Clin Nephrol 2004;62:35-43.  Back to cited text no. 1
    
2.
Selby NM, Fialova J, Burton JO, McIntyre CW. The haemodynamic and metabolic effects of hypertonic-glucose and amino-acid-based peritoneal dialysis fluids. Nephrol Dial Transplant 2007;22:870-9.  Back to cited text no. 2
    
3.
Szeto CC, Chow KM, Kwan BC, Chung KY, Leung CB, Li PK. New-onset hyperglycemia in nondiabetic Chinese patients started on peritoneal dialysis. Am J Kidney Dis 2007;49:524-32.  Back to cited text no. 3
    
4.
Grodstein GP, Blumenkrantz MJ, Kopple JD, Moran JK, Coburn JW. Glucose absorption during continuous ambulatory peritoneal dialysis. Kidney Int 1981;19:564-7.  Back to cited text no. 4
    
5.
Góes CR, Berbel MN, Balbi AL, Ponce D. Metabolic implications of peritoneal dialysis in patients with acute kidney injury. Perit Dial Int 2013;33:635-45.  Back to cited text no. 5
    




 

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  In this article
Abstract
Glucose Absorption
Protein Loss
Hyponatremia/hyp...
Lipid Abnormalities
Other Electrolyt...
References

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